Respiratory medicine: Hoover sign: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Respiratory medicine: Hoover sign

Sample item

A 68-year-old smoker with severe emphysema is breathless. On inspection the lower costal margins move inwards during inspiration. What explains this sign?

AFlattened diaphragm pulling the lower ribs inwards as it contractsBWeakness of the external intercostal musclesCParalysis of the diaphragm on one sideDPleural adhesions fixing the lower ribs

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

A. Flattened diaphragm pulling the lower ribs inwards as it contracts

In hyperinflation the diaphragm is flat, so its contraction pulls the lower rib margin inwards instead of lifting it outwards, which is the Hoover sign. It indicates severe airflow obstruction. A paralysed diaphragm gives paradoxical upward movement of the abdomen, not the sign described.

Option by option

A. Flattened diaphragm pulling the lower ribs inwards as it contracts (correct)
Correct. A flat, low diaphragm acts on the rib margin and draws it inwards.
B. Weakness of the external intercostal muscles
Intercostal weakness does not explain the active inward pull in hyperinflation.
C. Paralysis of the diaphragm on one side
Unilateral diaphragmatic paralysis causes paradoxical upward movement on that side, not bilateral inward rib movement.
D. Pleural adhesions fixing the lower ribs
Adhesions would restrict movement rather than draw the margins inwards.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is A, Flattened diaphragm pulling the lower ribs inwards as it contracts. In hyperinflation the diaphragm is flat, so its contraction pulls the lower rib margin inwards instead of lifting it outwards, which is the Hoover sign.

Why is "Weakness of the external intercostal muscles" not the answer?

Intercostal weakness does not explain the active inward pull in hyperinflation.

Why is "Paralysis of the diaphragm on one side" not the answer?

Unilateral diaphragmatic paralysis causes paradoxical upward movement on that side, not bilateral inward rib movement.

Why is "Pleural adhesions fixing the lower ribs" not the answer?

Adhesions would restrict movement rather than draw the margins inwards.

What concept does this question test?

It tests Respiratory medicine: Hoover sign in General Medicine. It indicates severe airflow obstruction. A paralysed diaphragm gives paradoxical upward movement of the abdomen, not the sign described.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Respiratory medicine: Hoover sign?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.